Ticagrelor monotherapy associated with less bleeding risk than dual antiplatelet therapy
In patients with acute coronary syndrome who received drug-eluting stents, ischemic outcomes did not differ with continued dual antiplatelet therapy versus de-escalation after a few weeks and up to three months to ticagrelor monotherapy, while bleeding risk was lower with the latter, according to a meta-analysis.
De-escalating dual antiplatelet therapy (DAPT) to ticagrelor monotherapy was associated with a lower risk for major bleeding, with no increase in ischemic events, in patients with acute coronary syndrome (ACS) who had received a drug-eluting stent, a review and meta-analysis found.
The review included data from three randomized controlled trials comprising 9,130 patients with ACS to evaluate the efficacy and safety of de-escalating DAPT to ticagrelor monotherapy. Of the ACS patients included in the analysis, 3,132 had ST-segment elevation myocardial infarction (STEMI), 3,023 had non-STEMI (NSTEMI), and 2,975 had unstable angina. About half of the patients had been randomly assigned to de-escalation of DAPT to ticagrelor monotherapy, and the remaining half were assigned to standard DAPT. The review was published Feb. 18 by Annals of Internal Medicine.
The rate of the primary ischemic end point (a composite of death, nonprocedural myocardial infarction, or stroke) did not differ between the ticagrelor monotherapy and standard DAPT groups (1.7% vs. 2.1%; hazard ratio [HR], 0.85 [95% CI, 0.63 to 1.16]). The rate of the primary bleeding end point was lower in the ticagrelor monotherapy group (0.8% vs. 2.5%; HR, 0.30 [95% CI, 0.21 to 0.45]). These findings were consistent in patients with STEMI, NSTEMI, and unstable angina.
The study authors wrote that de-escalating DAPT to ticagrelor monotherapy in patients with ACS getting a drug-eluting stent could be a feasible treatment option to avoid aspirin-associated major bleeding.
“[O]ur findings support the approach of transitioning from short DAPT to ticagrelor monotherapy to reduce the risk for bleeding without increasing ischemic risk,” the authors wrote. “Meanwhile, differences in adherence to ticagrelor between the randomized clinical trial population and the general population should be considered, particularly given its twice-daily dosing requirement; nonetheless, even when accounting for the most common dosing omissions of missing a single dose, ticagrelor's effect on platelet inhibition remained acceptable.”